Supervisory Referral Forms - University Of Rochester Medical Center printable pdf download

Supervisory Referral Forms - University Of Rochester Medical Center

UR Medicine EAP Supervisory Referral Protocol

1. Supervisor identifies employee job performance problem and reviews with

designated Human Resources Representative.

2. HR completes the UR Medicine EAP Supervisory (Job Performance Referral

Form.” Please note: Referral Form will be shared with employee.

3. Supervisor discusses the job performance referral to EAP with the employee,

and provides contact information for UR Medicine EAP to obtain an

appointment. Supervisor gives the employee a clear time frame within which

employee is expected to call EAP (usually 24 hours). Employee is provided

with Authorization to Release Information form to sign, allowing UR

Medicine EAP to confirm when initial appointment is scheduled and

attended.

4. HR sends to UR Medicine EAP via confidential fax 475-9516 the following

forms: completed Supervisory Referral form, copies of written documentation

of disciplinary action and signed Authorization to Release Information form.

5. UR Medicine EAP will notify HR when the employee has scheduled the initial

appointment.

6. At first meeting with the EAP clinician, a signed Release of Information

Form will be obtained from the employee, which will allow UR Medicine EAP

to contact HR with follow-up information. A Job Performance Referral

Follow-up Form will be completed at routine intervals to keep HR updated

on the employee’s progress.

7. If an employee is referred outside the EAP for treatment, the employee must

sign a Release of Information Form allowing UR Medicine EAP to

maintain contact with HR and the treating clinician and act as an

intermediary. UR Medicine EAP accepts the responsibility to monitor the

employee’s progress and routinely report back to the HR Representative using

the follow-up form. This process allows EAP the opportunity to continually

monitor the compliance of the employee and treatment progress.

8. UR Medicine EAP will provide education and support to address issues

contributing to performance issue. Supervisors will continue to monitor and

address performance. The Job Performance Referral Process will terminate

when UR Medicine EAP counselor, in consultation with HR liaison,

determines that client has successfully completed treatment plan.

Supervisory Referral Forms - University Of Rochester Medical Center